Brain attach should be tackled like a heart attack. As time is brain, a patient with suspected paralysis/stroke or brain attack should be shifted to hospital at the earliest and given a clot dissolving therapy if the CT scan is negative for brain hemorrhage. Prevention for paralysis is the same as prevention for heart attack. All patients with paralysis should undergo testing for underlying heart disease and all patients with heart diseases should undergo testing to detect blockages in the neck artery which can cause future paralysis.

Facts

One should rule out brain hemorrhage as soon as possible.

Obtain emergent brain imaging (with CT or MRI) and other important laboratory studies, including cardiac monitoring during the first 24 hours after the onset of ischemic stroke.

Check glucose and correct high or low sugar. If the blood sugar is over 180 mg/dL start insulin.

Maintain normothermia for at least the first several days after an acute stroke.

For patients with acute ischemic stroke who are not treated with thrombolytic therapy, treat high blood pressure only if the hypertension is extreme (systolic blood pressure >220 mmHg or diastolic blood pressure >120 mmHg), or if the patient has another clear indication (active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or pre–eclampsia/eclampsia).

For patients with acute ischemic stroke who will receive thrombolytic therapy, antihypertensive treatment is recommended so that systolic blood pressure is ≤185 mmHg and diastolic blood pressure is ≤110 mmHg.

Antithrombotic therapy should be initiated within 48 hours of stroke onset.

For patients receiving statin therapy prior to stroke onset it should be continued.

eMedipics

Press Conference in Varanasi

Managing rheumatoid arthritis: Changing paradigms, changing practices

Dr Anand N Malaviya, New Delhi

Rheumatoid arthritis (RA) is treatable at any stage of disease provided treatment is ‘appropriate’.

In late presentation, you can control inflammation but structural damage persists.

RA is not only an arthritis, it is a multisystem inflammatory disease. CVD is the invisible complication of RA.

RA has the same risk for CVD as type 2 diabetes; the cause of death in late RA is CAD.

If treatment is started early, inflammation controlled, structural damage is prevented; CAD is also prevented.

From 1800 to 50s and 60s: treatment included willow bark extract, aspirin; then came newer NSAID

Then came the pyramidal approach – Go slow go low. The major goal was symptom relief. Start treatment with milder drugs, steroids. The achievement of pyramidal approach – patients were dying of premature heart disease, which nobody recognised. This approach was challenged by many clinicians.

Early RA is important as inflammation is greatest in the earliest stages with little clinical evidence, speed of joint destruction in early RA, functional decline is rapid in early stages. Once functional worsening has occurred, it is difficult to reverse.

Paradigm shift: Prevention of structural damage; control disease rather than pain.

1980 to mid–90s: evidence based treatment with conventional DMARDs as soon as RA is diagnosed. The goal of treatment was to control inflammation.

Mid 2005 to present: mechanism and evidence based treatment: Use window of opportunity where you can control disease; early aggressive treatment. The goal of treatment is to achieve remission or comprehensive disease control or drug free RA.

Very early treatment with DMARDs prevents joint damage and instability.

Do not treat RA unless you are able to measure disease activity: instruments (DAS28, CDAI, SDAI)

Low dose MTX has nothing to do with cancer drug, which is high dose MTX. They are two different drugs.

We now have biologics to achieve remission; challenges with biologics: Financial, regulatory and scientific.

Goals of therapy in RA

Remission in s/s of joint disease
Reduction of joint destruction
Reduction of disability
Reduction of mortality and improvement in QOL.

Dr Pritam Gupta, New Delhi

Poisoning in North India

Poisoning is a major problem worldwide.

Suicidal poisoning is very common in India. Homicidal poisoning is uncommon but not rare.

Farmer suicides are increasing. Over last 13 years, about 2.5 lakh farmers have committed suicide in India.

Acute poisoning is second only to RTAs in numbers, but it is often a neglected problem due to difficult in diagnosis, non-availability of antidote. But it is preventable.

Oral route is most common 88%.

Aluminum phosphide most common in rural areas; OP poisoning is common in other areas.

ALP poisoning: Factors correlating with outcomes include number of vomitings after ingestion and severity of shock and acidosis. Diagnosis is by detecting phosphine in exhaled air. Supportive treatment as no antidote, hence high mortality.

Zinc phosphide similar to ALP but not so common or fatal as insoluble in water.

There is a bidirectional relationship between diabetes and depression.

Depression has a negative impact on management and progression of diabetes: Reduced adherence to medication, greater use of ambulatory care, more likely to experience functional disability, more complications.

If serum 25 OH D level below 80 nmol/l are not adequate; to reach level of 80, at least 1000 IU/day is required.

Vitamin D has lot of facts, but it also has lot of myths.

Dr KK Spiritual Blog

Why do We Burn Camphor In Any Pooja?

No Aarti is performed without camphor. Camphor when lit burns itself out completely without leaving a trace of it.

Camphor represents our inherent tendencies or vasanas. When lit by the fire of knowledge about the self the vasanas burn themselves out completely, not leaving a trace of ego.

Ego is responsible for a sense of individuality that keeps us separate from the Lord or consciousness.

In addition, camphor when burns, emits a pleasant perfume. This signifies that as we burn our ego we can only spread love and nothing else.

Event

Cardiology eMedinewS

A new study of more than 1000 frail people in their 80s and 90s living in nursing homes raises a cautionary note regarding the safety of using combination antihypertensive therapy in frail elderly patients with low systolic blood pressure. These findings from the Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population (PARTAGE) longitudinal study are published online February 16, 2015 in JAMA Internal Medicine.

Performance of PCI via the transradial route was independently associated with reduced risk of major acute coronary events (MACE), 30–day mortality, and major bleeding outcomes across all age groups, compared with transfemoral procedures, in an analysis based on a large cohort of patients in the UK

Pediatrics eMedinewS

Randomized trial data from Yun Kwok Wing, FRCPsych, and colleagues from the Chinese University of Hong Kong SAR, China, published online February 16 in Pediatrics reveals that US adolescents became progressively more sleep-deprived after 1990. Girls were more likely to be affected than boys, as were racial/ethnic minorities, city dwellers, and those from poor families. Teenagers from racial/ethnic minorities and from poor families were likely to think they were getting enough sleep even when they were not.

The new 9–valent vaccine against human papillomavirus (HPV), known as Gardasil 9 (Merck & Co.), that was recently approved in the United States has been shown to offer additional protection against oncogenic strains of the virus, according to a study in the February 19 issue of the New England Journal of Medicine.

Make Sure

Situation:A 62–year–old–diabetic with coronary artery disease, on treatment for the same, comes for follow up.
Reaction: Oh my God! Why did not you put him on antioxidants?
Lesson: Make Sure to add antioxidants to the prescription because of their free radical scavenging and other beneficial effects.

Medicolegal

(Contributed by Dr MC Gupta, Advocate)

Q. I have the following qualifications: B.Sc. (MLT), P.G.D.C.P; M.Sc. (Micro). Can I start my own diagnostic laboratory?

A

It seems you do not have a medical qualification. The so called PGDCP, if it means Post Graduate Diploma in Clinical Pathology, is probably a misnomer and is not a recognised qualification and has been probably given by an unrecognised institution. You do not seem to be entitled to put the prefix Dr. before your name.

In view of the above, you are not legally competent to start your own diagnostic laboratory independently because that amounts to practice of pathology which is a medical specialty.

However, you can own the laboratory and can employ a pathologist or enter into a partnership with him with an arrangement that he medically supervises the laboratory and interprets and signs the reports.

Dr Good Dr Bad

Situation: A patient with Mediclaim of 2 lakhs of seven years duration needed a claim of Rs. 2.2 lakhs.
Dr. Bad: You will have to pay Rs. 20,000 from your pocket
Dr. Good: You can claim cumulative bonus.

Lesson:: Sum insured under the policy shall be progressively increased by 5% for each claim–free year of insured subject to maximum accumulation of 10 claim–free years of insurance.

If a person is on antimalarials or steroids or taking immunosuppressant drug, what is the schedule for rabies vaccine?

The vaccine on Day 0 (first injection) must be doubled and given at two sites (deltoids or thigh in young children). In category II exposures, it is recommended to administer even RIGs along with vaccine. Rest of the schedule is same as for any other patient.

Sameer Malik Heart Care Foundation Fund

The Sameer Malik Heart Care Foundation Fund is a one of its kind initiative by the Heart Care Foundation of India instituted in memory of Sameer Malik to ensure that no person dies of a heart disease because they cannot afford treatment. Any person can apply for the financial and technical assistance provided by the fund by calling on its helpline number or by filling the online form.

Thirteen years after the last National Health Policy, the Ministry of Health has brought out a new draft National Health Policy, which is already in the public domain. Indian Medical Association place on record its appreciation for immediately bringing out a National Health Policy soon after assuming power. The National Health Policy of 1983 and that of 2002 have served us well, in guiding the approach for the health sector in the Five–Year Plans. Development of a more robust, effective and credible new National Health Policy will give direction and coherence to our efforts further to improve health of the nation.

The importance given to urban health, addressing social determinants of health, suggestions to harness newer technologies like tele–medicine, recognizing the role of private sector through health strategic purchasing, newer strategies for resource generation like health cess etc. are appreciable.

Indian Medical Association (IMA) feels that the policy, should give greater focus for preventive and rehabilitative care in the context of rising burden of non–communicable diseases. However the IMA is of the view that greater contribution in terms of GDP will be required to attain the set goals in the present policy. The association feels that at least around 5% of GDP needs to be earmarked for health. The policy recommends setting up of task forces for developing indicators and targets and mechanisms for achievement. While task force for implementation of programme makes sense, it is mandatory that the policy clearly spells out indicators and targets. For any task force the scope and target should be predefined, if not the task force will come out with its own indicators and targets, which could be contrary to the philosophy of the policy.

Strengthening the family planning program, improving medical education, school health education, programmes for health of the elderly, mental health, four tier system of health care, family doctor concept, health manpower assessment, improving overall efficiency of health management, addressing intra state and inter state disparities and system for monitoring and expenditure tracking, IMA feels, are all important areas where the health policy needs to focus more. A large part of allocation of funds are usually spent on pay and allowances, pensions, transport and establishments, hence funds for actual expenditure on health and medical care needs to be increased and specified. There should be a permanent mechanism to monitor the utilization of funds and to ensure that funds reach the targeted population for whom it is intended. There is need for inculcating better managerial skills for which an Indian Medical Service like IAS and IRS is required.

The private health providers cannot be bracketed together the small and medium level health institutions play a distinct role in supplementing the government health sector by serving in rural and remote areas, making health care accessible and affordable to the weaker sections of the society. In fact, these small players move the national health indices. The presence of corporate sector is largely in major cities and contributes to tertiary care. The policy needs to give special importance and consideration to the small and medium level institutions for its complementary role, while giving due importance to the corporate sector with adequate scope for independent existence and growth of both the sectors.

Health and Education are fundamental rights of the citizen. Just as the Government is promoting education through aided schools, health needs to be promoted by introducing the novel concept of aided hospitals. If not, the policy will become more beneficial to people who can afford even otherwise. The concept of comparative efficiency as proposed in the policy, needs to be closely examined. Value for money is a myth since even those who seek health care from public sector do spend from Out Of Pocket, the same amount as in private sector.

The policy, which is silent on Health Human Resource Development, needs to spell out clear cut directions to curb the uncontrolled, unregulated expansion of these sectors as has happened so far; and to ensure more uniform and even distribution of institutions with emphasis on needy and backward areas. The medical council should be made more strong and autonomous by incorporating provisions for accreditation medical grants commission and mechanisms for facility augmentation and staff promotion activities. There is a need for proportionate production of all streams of health manpower personal on the basis of manpower requirement so that the pyramidal structure of health delivery is retained.

Quality assured drugs should be made available through the public distribution system to make them affordable. The drug quality control mechanism should be strengthened. The apprehensions following the recent amendments in the drug patent laws need to be addressed and the escalation of cost of drugs consequent on these legislations need to be prevented. The government should invest more resources in research on development of new drugs and devices. Just like techno parks, common facilities for drug research and quality assurance need to be established. ‘Make In India policy’ should be extended to manufacturing of Drugs, life saving equipments and devices.

Since the private sector provides care for 70 percent of the population due consideration needs to be given to it. Income tax, luxury tax and service tax in hospitals and VAT on drugs goes contrary to this. Government policy should influence and encourage private health care establishments by exempting them from the purview of income tax and providing subsidies. Government also should provide water, electricity and basic amenities at reduced rates for private hospitals. Government in turn can demand a major role for these institutions in public health and curative services. Poor needs to be provided free or subsidized health care in these institutions. This will reduce the cost of care eventually avoiding catastrophic health expenses. This model will be cost effective compared to heavy investments required in health insurance systems. Failure of American model insurance - driven health care provisioning should be a lesson while framing the policy

Considering private hospitals as pure industry is entirely misleading and it contradicts the Government policy of making health as a fundamental right. Private health care is a service sector governed by medical ethics. When the Government demands that medical ethics need to be followed and considers it as a service sector, branding clinical establishments in private sector as an industry exposes a contradiction. The pre–conceived notion that private sector is profit–driven and ignoring it in the overall structure of health delivery, allowing it to run parallel to the Government sector rather than promoting them to compliment, goes against the spirit of this policy.

The need for standardization and quality health care services is understandable, but the mechanism to ensure it through Clinical Establishment Act will be counter–productive. A process of voluntary and incentive driven accreditation is the best practical option where professional organizations like IMA can play a pivotal role.

The integrated medicine concept is again a misplaced thought process, which is not based on ground reality or evidence. When different systems of medicine are available, public always would like to try a different system when one system fails. Through the integration of systems, the Government is denying the right of the public to choose a pure alternate system. It is not their desire to opt for a different system when the process of integration has already diluted it. Integrating different systems of medicine, which have diametrically opposite basic principles, will only lead to destruction of these systems. Modern medical degree should be made the basic qualification to practice medicine. All other systems of medicine should be learned only after acquiring basic modern medicine degree, that is MBBS and not in the reverse order. In all other countries including Germany where Homeopathy took origin, a modern medical degree is a prerequisite to learn any other system of medicine.

IMA feels that the new policy document does not make a strong case for moving towards our objective of universal access to affordable health-care. There are innumerable challenges to be overcome before its stated objectives become a reality. IMA demands serious deliberations and consultations with all stakeholders including professional associations before the policy is finalized. IMA being the biggest stakeholder in health scenario in India, our views should be seriously considered before finalizing the policy.

Regarding burnout and citizenship status, burnout rates are lowest in family physicians who came to the United States as adults, with 41% saying they are burned out vs 52% of those who were born in the US and 53% who have been here since childhood. This survey does not explain the discrepancy, although one physician offers a sobering thought. Commenting in a recent Medscape article on physician suicide, the writer said, "I am a doctor in Mosul, Iraq, actively practicing since 1977. What stress (is there) in the USA?"

Media

Quote of the Day

Determine what specific goal you want to achieve. Then dedicate yourself to its attainment with unswerving singleness of purpose, the trenchant zeal of a crusader.

Inspirational Story

Saying Grace in a Restaurant!

Last week I took my children to a restaurant. My six–year–old son asked if he could say grace.

As we bowed our heads he said, "God is good. God is great. Thank you for the food, and I would even thank you more if Mom gets us ice cream for dessert. And Liberty and justice for all! Amen!"

Along with the laughter from the other customers nearby I heard a woman remark, "That’s what’s wrong with this country. Kids today don’t even know how to pray. Asking God for ice–cream! Why, I never!"

Hearing this, my son burst into tears and asked me, "Did I do it wrong? Is God mad at me?"

As I held him and assured him that he had done a terrific job and God was certainly not mad at him, an elderly gentleman approached the table. He winked at my son and said,

"I happen to know that God thought that was a great prayer."

"Really?" my son asked.

"Cross my heart," the man replied.

Then in a theatrical whisper he added (indicating the woman whose remark had started this whole thing), "Too bad she never asks God for ice cream. A little ice cream is good for the soul sometimes."

Naturally, I bought my kids ice cream at the end of the meal. My son stared at his for a moment and then did something I will remember the rest of my life. He picked up his sundae and without a word, walked over and placed it in front of the woman. With a big smile he told her, "Here, this is for you. Ice cream is good for the soul sometimes; and my soul is good already."

Wellness Blog

Seven behaviors cut heart deaths

Seven heart–healthy behaviors can reduce the risk of death from cardiovascular disease. In a prospective study by Enrique Artero, PhD, of the University of South Carolina and colleagues and published in the October issue of the Mayo Clinic Proceedings, those who met 3–4 of the American Heart Association’s ‘Simple Seven’ heart–health criteria had a 55% lower risk of cardiovascular mortality than those who met no more than two of those practices over 11 years.

Dear sir, Greetings, Very good initiatives, "TB Mukt Bharat,TB Haarega,Desh Jeetega" it should be conveyed in all Indian languages in the respective states. Simultaneously to have great effect in awareness notification. With best wishes, Sincerely yours, Dr.Har Vinod Jindal

An old lady went to her doctor to see what could be done about her constipation. "It’s terrible," she said. "I haven't moved my bowels a week." "I see have you done anything about it?" asked the doctor" Naturally", she replied. " I sit in the bathroom for a half hour in the morning and again at night"."No," the doctor said," I mean do you take any thing?" "Naturally" she answered, "I take a book."

eMedi Quiz

Thirty–eight children consumed eatables procured from a single source at a picnic party. Twenty children developed abdominal cramps followed by vomiting and watery diarrhea 6–10 hours after the party. The most likely etiology for the outbreak is:

Announces partnership with the Indian Medical Association, Varanasi branch to support young girls and widows in the city in need of heart surgery but cannot afford treatment

After successfully saving lives of people in Delhi NCR and Vrindavan, Heart Care Foundation of India, a leading national non-profit organization today launched its initiative, the Sameer Malik Heart Care Foundation Fund in Varanasi. The ideology behind the project being no person dies of a heart disease just because he or she cannot afford treatment. Any person irrespective of their gender, religion or age can apply for the benefits of the fund by calling its local contact person Mr. Manoj on 09305177411. The NGO also announced a partnership with the local branch of the Indian Medical Association to

Heart diseases have emerged as the number one killer in both urban and rural areas of the country. However, not many are aware of the fact that most of the heart conditions are curable and death is preventable if timely precautions are taken. There are many people in India who cannot afford the treatment and hospital costs. The Sameer Malik Heart Care Foundation Fund is an attempt to bridge this disparity and provide individuals the ability to live a healthy– and disease–free life. Since the inception of the project in April 2014, over 300 patients belonging to economically weaker sections of the society have already been helped and treated. The aim is to take this number up to 600 in the coming year.

Speaking on the occasion, Padma Shri Awardee Dr. KK Aggarwal who is the Honorary Secretary General, Indian Medical Association and President of the Heart Care Foundation of India said, “Every year about 78,000 infants born with congenital heart disease in India die due to lack of medical care. Most of these are girls because parents do not want to spend an enormous amount of 3 to 5 lakhs on them. In addition to this widows in India live a life of social and cultural deprivation where they are denied even the basic right of leading a healthy life. We at Heart Care Foundation of India believe that no person, irrespective of their financial status deserves to die just because they can’t afford treatment. Through this alliance with the Indian Medical Association Varanasi branch, support of the Malik and Kumar family and newly launched local Heart Care Foundation of India office, we hope to help save the lives of these people.”

Mr. Arvind Kumar. Advisor and Mr. Vivek Kumar, Trustees of Heart Care Foundation of India in a joint statementsaid, “There are a lot of poor people in Banaras who cannot afford medical treatment and succumb to diseases because of their financial background. We are extremely happy to take the responsibility of the local branch of Heart Care Foundation of India in the beautiful and holy city of Varanasi and hope to help save the lives of many people in the future”.

Adding to this, Dr. N P Singh, President, Dr. Arvind Singh, Secretary and Dr. Kartikeya Singh, Finance Secretary of IMA Varanasi branch in a joint statement said, “The Sameer Malik Heart Care Foundation Fund is a noble project aimed at providing effective solutions for the economically weaker sections of the society and IMA Varanasi is extremely proud to be associated with it. We hope that this partnership would be instrumental in providing people of Varanasi especially the widows and girl children the best possible financial and technical assistance needed for the cure of any form of cardiac problems.”

The launch was followed by a musical concert by Padma Bhushan Pandit Rajan Sajan Mishra on the banks of river Ganga on Saturday evening. This concert was an initiative by to raise mass awareness among people about the preventive measures for cardiac ailments and timely treatment for the same.

Mr. Deep Malik, in whose brother’s memory the project has been institued said,”I congratulate Heart Care Foundation of India for their launch of Sameer Malik Heart Care Foundation Fund in Varanasi. With each life saved, Sameer continues to live in our hearts”.

The helpline number for the Sameer Malik Heart Care Foundation Fund 09305177411 is open from Monday to Saturday from 9 AM to 5 PM. Individuals who wish to apply online can download the application form from the website, http://heartcarefoundationfund.heartcarefoundation.org/. An expert committee comprising of notable individuals would assess all applications received by the fund. Once sanctioned, the funds would be directly deposited in the bank account of the medical establishments treating the patient. All surgeries will be conducted in leading hospitals in New Delhi. Staying facilities at consessional rates will be provided to patients.